[Addressee:Full Details]
[Miscellaneous:Date]

Dear [Addressee:Greeting]

I have started a  Care Plan for:	[Patient Demographics:Full Name]
[Patient Demographics:Full Details]
DOB:[Patient Demographics:DOB] File No. [Patient Demographics:Record Number].

Please find a draft copy of the Care Plan attached.  I invite you to contribute any information to enhance the care plan below in addition to what was discussed earlier.

Please tick one:
____ this is a new referral; or
____ this is a patient you already see, and according to my records, this patient is due to see you in:
	Month		Year

A separate referral letter is included: (Please tick one)	____ Yes	____ No.
Yours sincerely
[Doctor:Name]  Provider No. [Doctor:Provider Number]
CC: Care Plan attached .
-----------------------------------------------------------------------------------------------------------------
The part below is just to formalise your agreement to participate in Team Care:
Do you agree to be named as a Care Plan Team Member and to provide the services suggested in the attached draft?   
Please tick one:

   ____ YES

.............................................................................................................................. (signature)
If yes, please sign here and faxback to the surgery at the number below.  

   ____ NO
If you do not want to participate in the Care Plan please advise me as soon as possible so that I can arrange an alternate plan.

I suggest that the patient would benefit from the following Goals and Actions:
1. as per draft Care Plan submitted
2...........................................................................................................................................................................

PLEASE FAX BACK TO 95340637